A nurse is reviewing the ECG tracing strip of a client who is receiving telemetry monitoring.
The nurse should locate the S-T segment at which of the following locations on the electrocardiographic waveform.

Choice A rationale

Chilling the lavage fluid causes vasoconstriction of the gastric blood vessels, which helps to slow or stop the bleeding. The cold temperature directly constricts the capillaries and arterioles in the stomach lining, reducing blood flow to the bleeding site. This action is a primary goal of gastric lavage in cases of upper gastrointestinal hemorrhage.

Choice B rationale

Positioning the client on their left side is the appropriate action. This position allows the lavage fluid to pool in the greater curvature of the stomach, where it can be most effective at washing over the bleeding site. Placing the client on their right side would cause the fluid to quickly pass into the duodenum, which is less effective for gastric lavage.

Choice C rationale

Gastric lavage is performed to remove blood and clots from the stomach. The procedure involves instilling a fluid, typically saline, and then withdrawing it. The nurse continues this process, manually withdrawing the fluid, until the return fluid is clear or only slightly pink, which indicates that the bleeding has been controlled or significantly reduced.

Choice D rationale

A large-bore NG tube (16-18 French or larger) is preferred for gastric lavage in cases of upper gastrointestinal bleeding. A large-bore tube is necessary to effectively remove blood clots and viscous fluid from the stomach. A small-bore tube would easily become occluded by clots, rendering the lavage procedure ineffective. *.

Choice A rationale

This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.

Choice B rationale

A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.

Choice C rationale

A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.

Choice D rationale

A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .